Download File - Safe Surgery 2015

Ambulatory Safe Surgery Checklist template
Before Patient is Sedated
Nurse and Anesthesia Professional verify with the Patient:
 Patient identification (name and DOB)
 Surgical site
 Surgical procedure to be performed matches the consent
 Site marked
 Known allergies
 Patient positioning
 Patient weight
Nurse and Anesthesia Professional verify:
 Implants available in the OR
• Correct type and size
 Essential imaging available
 Risk of hypothermia (if operation >1 hour)
• Warmer in place
 Risk of venous thromboembolism
• Boots in place and/or anticoagulants
 Anesthesia safety check completed
Nurse and Anesthesia Professional share:
 Anticipated airway or aspiration risk
 Changes in patient’s cardiac history
 Changes in patient’s respiratory history
This version of the Safe Surgery Checklist template is intended for ambulatory surgery centers.
This checklist is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged.
Based on the WHO Surgical Safety Checklist (http://www.who.int/patientsafety/safesurgery/en)
© 2008 World Health Organization All rights reserved.
ASCSSC-2page.1 Revised: 7 August 2015
Hospital Name
Ambulatory Safe Surgery Checklist template
Hospital Name
Before Procedure Is Started
Before Patient Leaves Room
TIME OUT
Nurse reviews with team:
 Instrument, sponge, and needle counts
 Name of the procedure performed
Circulating Nurse asks:
“Is everyone ready to perform the time out?
Please state your name and role.”
Entire Team confirms:
 Patient name
 Surgical procedure to be performed
 Surgical site
 Essential imaging available
 Antibiotic prophylaxis given within the last
60 minutes
Nurse reads aloud to team:
 Specimen labeling, including patient's name
TEAM DEBRIEFING
Entire Team discusses:
 Key concerns for patient recovery and management
 Equipment problems that need to be addressed
 Other opportunities for improvement
TEAM BRIEFING
Surgeon/Proceduralist shares:
 Any changes to procedure plan
 Possible difficulties
Anesthesia Professional shares:
 Anesthetic plan
 Airway concerns
 Other concerns
Circulating Nurse and Scrub Tech share:
 All medications are correct and labeled
 Implant type and size
 Equipment availability or issues
 Other concerns
Surgeon/Proceduralist asks:
“Does anybody have any concerns?
If you see something that concerns you
during this case, please speak up.”
This version of the Safe Surgery Checklist template is intended for ambulatory surgery centers.
This checklist is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged.
Based on the WHO Surgical Safety Checklist (http://www.who.int/patientsafety/safesurgery/en)
© 2008 World Health Organization All rights reserved.
ASCSSC-2page.2 Revised: 7 August 2015